Health Literacy Universal Precautions Toolkit, 2nd Edition

Brief Patient Feedback Form

[Microsoft Word file Microsoft Word version - 20.78 KB]

We would like your honest feedback. Please answer these questions either yes or no about the visit you had today. Think about a specific provider or staff member—for example, your doctor, nurse, medical assistant—when answering.

1. Did this clinician or staff member explain things in a way that was easy to understand? Yes No
2. Did this clinician or staff member use medical words you did not understand? Yes No
3. Was this clinician or staff member warm and friendly? Yes No
4. Did this clinician or staff member listen carefully to you? Yes No
5. Did this clinician or staff member encourage you to ask questions? Yes No
6. Did this clinician or staff member answer all your questions to your satisfaction? Yes No
7. Did you see this clinician or staff member for a specific illness or for any health condition? Yes No
If No, Form Is Complete
   a. Did this clinician or staff member give you instructions about what to do to take care of this illness or health condition? Yes No
If No, Form Is Complete
   b. Were these instructions easy to understand? Yes No
   c. Did this clinician or staff member ask you to describe how you were going to follow these instructions? Yes No

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Page last reviewed February 2015
Page originally created February 2015
Internet Citation: Brief Patient Feedback Form. Content last reviewed February 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool4d.html